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FOR OFFICE USE: - ` <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. ._�� <br /> r. = (Complete in Triplicate) <br /> ------ ------------ -------------------------- <br /> This Permit Expires 1 Year From Date Issued Date issued _. ____= - <br /> Application is'hereby made to the San Joaquin Local Health District for a permit to construct and install the;'work herein <br /> described. This appliois made lin compliance with County Ordinance No. 549 and existing-Rules and Regulations: <br /> JOB ADDRESS/LOCATa -------- ---- - -------------- ---�`-'�`�=`�- "---- - --CENSUS TRACT =` <br /> Owner's Name ---- £ Phone 5 <br /> 3 Address ---- ��_ --G, P------ ----------------•--. City ------- ' <br /> Contractor's Name _.__ --------------_�-----�" S_�_---'l- hfense # Phone --_-- --- - - -�•- - <br /> -- ----------------------- - <br /> Installation will serve. Residence [N Commercial :❑Trai erCourtti❑ <br /> i Motel ❑Other --------------------------------------------- + - <br /> 4 Number of living units:------------ Number of bedrooms _3------ Grinder ----------__ Lot Size -------------------___________--_______._.. <br /> Water Supply: Public System and name ------------------------------------ ------------------------------------i----------•-------- _Private <br /> ivate <br /> Character of soil to a depth of 3 feet: Sand!❑ Silt❑ _ Clay Peat ❑_ Sandy,L`ocirri ❑ Clay Loam ❑ <br /> l Hardpan ❑ Adobe❑ Fill Material ------------- If yes; type --- <br /> � <br /> i (Prot plan;"showing size of lot, location of system in relation to wells, buildings, etc.'.must be placed on reverse side.) "f <br /> NEW INSTALLATION: ( o septic tank or seepage pit permitted if public sewer is availsle within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK { ] `f'r9'�� Size" 1-),_0__Q__-.__ -!`-W4quid Depth ____ _..._______ ('' <br /> 6 ___ sllaterial____ 5+-■ - -- N Compartments <br /> Capacity 12 0-.--- Type - . - ---- <br /> Distance to nearest: Well ----- Jf--______Foundation <br /> .-l�__.______-"___ Prop. Line <br /> LEACHING L•INE [OXNo. of Lines ------:3 Length of each line-----_CID/------- ---- Total Length ----�2._7_a.-------.- <br /> 'D' Boz•_-_ ___ Type Filter Material ----- �_____Depth Filter Material -----49�.._____ ------------------- <br /> If <br /> Distance to nearest: Well _____ C_-�________ Foundation -___-e�0_------------- Property Line -----671 <br /> ____6'1............. <br /> Diameter __ ___________ Number --------_______------_____ Rock Filled Yes No 0 <br /> SEEPAGE PIT: [ ] Depth _"__------- ❑ <br /> WaterFable Depth ------------------------------------------------Rock Size ------------------------- ------ <br /> r - i' <br /> Distance.to nearest: Well _______________________________________Foundation -------------------- Prop. Line ------------- ........ <br /> ' REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ____--'____________-__-__________) <br /> Septic Tank (Specify Requirements)e--------------,_=;- ------------------------------- -- ---------------•--•--•- - <br /> ------------------------------------------------ <br /> Disposal Field {Specify Requirements) ----- ---- --------------------------------------- ------------------------------------------------- ------- ------- <br /> 4 - ---------------------------------------------------------------------------------- ------------------------------------------------- ---•---------- <br /> ---- ----------------------- -------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws„and Rules and Regulations of the. San Joaquin local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California.” <br /> Signed ----------------- ", Owner <br /> By - ------ ----------------------------- ------------- ----------------------- Title <br /> (If other than owner) <br /> FO - _ EPARENT USE ONLY J / <br /> APPLICATION ACCEPTED BY ----- ---r-- ---- -`-`------ ---------- DATE ._.ljJ� `'7/----------------- <br /> BUILDING PERMIT ISSUED ------ -- ------ ---- --- - -- -------- -- -------- -------------- --------- --------------DATE ------- -------------------•--------- <br /> ADDITIONALCOMMENTS ----- -- - ------ - -- - -------------------------------------------------------- ------ ----------- ------------------------------------------------ <br /> ------------------------------------------------------------------ <br /> -------------------------------------------------------------------------- ------------------------------------------- ---------- -------------------------------------------------------------- <br /> l/ <br /> '�( T� <br /> FinalInspection by: ----------------------------------------------------------------------------- ----- --- ---- Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M <br />